Union_Well Abandonment_20221216

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WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water;Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:
5. WELL DETAILS:d� I i
a.Total Depth: 1 ft. Diameter: _ in.
We 1�C.ntractor(I ivtdual)Nat�e - b.Water Level(Below Measuring Point):Measuring point is ft.above land surface.
Well omp n ame
STREET A DRESS FI / 6. CASING: Length Diameter
r � a.Casing Depth(if known): ft. in.
it r own State Zip., odc '` '. �.s Y
r �ti b.Casing Removed: ft. in.
(AAreeaUcode-Phone number T DEC 1 V Zl'2Z 7. DISINFECTION:
2.WELL INFORMATION: � ,�l;;il (Amount of 65%-75%calcium hypochlorite used)
1ftGi�ti::.1071 ti':'�•.,ti,r.:':,t
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
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DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Circle applicable use): Monitoring Resi en
Municipal/Public, Industrial/Commercial Agricultural Bentonire Ib.'
Recovery Injection Irrigation T Type:ype:Slurr
Other(list use) — Water G`�gal.
Other
3.WELL LOCATION
COUNTY J,J(��QUADRANGLE NAME — Type material
NEAREST TOWN: Amount
/�A t✓ ! .
(Street/Road Name,Nullber,Community,Subdivision,Lot No.,Parcel,Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TOPOGRAPHIC/LETTWG:
Slope Valley lat Ridge Other
(Circle appropriate setting)
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May be in degrees,
LATITUDE _ minutes,seconds,or in a
LONGITUDE decimal format 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
Latitude/longitude source: GPS Topographic map form showing total depth,depth and diameter of screens(if any)remaining
(Location of well must be shown on a USGS topo map and in the well,gravel interval,intervals of casing perforations,and depths and
attached to this form iit'not using GPS.) types of fill materials used.
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b.
(If a residential well,skip 4a;complete 4b,well owner information only.) 11. DATE WELL ABANDONED
FACILITY ID#(if applicable)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY WITH 15A NCAC 2 ELL NSTR CTION STANDARDS,AND THAT A COPY OF
STREET ADDRESS
THIS RECORD He BEN PR VID TOT E WELL OWNER.
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City or Town State Zip Code IGNTCU'15P CIIRTIFIRD WE NTRACTOR DATE
4b.CONTAC PERS{ON/WELL O . NER:
NAME ' li SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
STREET DDRESS— r in accordance with 15A NCAC 2C.0113)
Ci y r T tt rate Zip Code PRINTED NAME OF PERSON ABANDONING THE WELL
AreaCode-Phone number y�
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Submit a copy to the owner and:the original to the Division of Water Quality within 30 days. I Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06
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WELL ABANDONMENT RE > For Internal Use ONLY:
1.Well Contractor Information: DEC 1 G2022 WELL ABANDONMENT DETAILS
K. Brandon Moore IIliO;i7a«i^.1 �;;�:��r„g. ura;l 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning wel!" hi'3/lieW4erty) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: Vnion Co. permit#22-455
List all applicable well consiniction permits(i.e.UIC,Conn%State,Variance,etc.)ifknoum 7 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
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❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 2 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier r
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled well completely to within 3 feet of land
surface with an 18-inch concrete plug
a.Date well(s)abandoned: 12/14/22 installed above top;of casing.
5a.Well location:
Primax Properties, LLC N/A
Facility/Owner Name Facility ID#(if applicable) S.Certification: /�
405 Sherin Lane 0. y�� V.-/T 12/14/22
Physical'Address,City,and Zip Signature of Certified Well Contractor of r Well Owner Date
Indian Trail, NC 28079 0710201OF
By signing this form,I hereby cer(ify that the well(s) was(were) abandoned in
County L t f r n Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well Idetails:
35.093333 N 80.662778 W You may use the back of this page;toj provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstructionrecord(s)ifavailable.For multiple injection or non-watersupplywells -
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 160 —(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): NIA (ft.) 10c.For Water Suouly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one lcopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft) abandoned.
6g.Screen length(if known): N/A (ft.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource) Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: Z. �'' u WELL ABANDONMENT DETAILS
K. Brandon Moore DEC 16 2022 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2957-A mT6�4 Jy=i3n F1i,=''''-'_.i lls"' wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hyp ochlorite
2.Well Construction Permit#: Union Co. permit#22-456 7c.Type of disi nfectant used:
List all applicable well constrnctionpermits(i.e.UIG County,State,Variance,etc.)ifknown 7 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 2 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer !
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled well completely to within 3 feet of land
surface with an 18;inch concrete plug
a.Date well(s)abandoned: 12/14/22 installed above top,of casing.
5a.Well location:
Primax Properties, LLC N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
407 Sherin Lane � � 12/14/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Indian Trail, NC 28079 07102010E
By signing this form, 1 hereby cert�that the wel!(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lit/long is sufficient) 9.Site diagram or additional well°details:
35.093889 N 80.662222 W You may use the back of this page to;provide additional well site details or well
abandonment details. You may also`attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach spell constrnctionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constracilon/abdndonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
fib.Total well depth:
140 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
fig.Screen length(if known): N/A
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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